Comments on "Children's Use of Summer Camp Health Facilities: A Longitudinal Study" by Louise Rauckhorst & Jane F. Aroian

Linda Ebner Erceg, RN, MS
Health & Safety Coordinator, Concordia Language Villages, Bemidji, MN
Executive Director, Association of Camp Nurses

Author Jane Aroian wrote to ACN's national office last fall to announce publication in the 1998 Journal of Pediatric Nursing (vol. 13 [4]) of a study she and fellow researcher, Louise Rauckhorst, completed. Their study is the most recent of the very few which exist about components of camp nursing practice. ACN members are encouraged to read the original article since it contains much more information than is presented in this comment.

Recognizing that "the summer camp health center allows children the freedom and self-responsibility to seek out health care on their own initiative," Rauckhorst and Aroian designed a study which examined the health care seeking behaviors of school aged children. Their descriptive work was based on a retrospective review of health center logs from three summer camps spanning years between 1977 and 1990. Using Lewis and Lewis' theoretical framework, a convenience sample (N = 370) was drawn of children who were campers during sequential summers in one of three summer camps participating in the study. Most children were healthy (without pre-existing medical conditions). Ages ranged from 6 years to 18 years; most of the participants (70%) had attended camp for two to five years.

The authors developed a taxonomy of "Reasons for Visits" to help categorize and code each child's visit to the health center. Limitations of the study included the nonrandom sample and use of the health center log as the only source of data about the camper's health seeking behavior. An alpha level of .05 was used to determine statistical significance of findings.

SELECTED RESULTS

Results indicated that accident/injury was the number one reason why children sought health care (30.6% of visits). This was followed by visits associated with communicable disease, most commonly upper respiratory infections (20.6%). The third most common reason (16.1%) for coming to the camp health center was for discomfort problems (i.e., headache, knee pain, dysmenorrhea) followed by seeking relief from allergy symptoms (12%). The study noted that visits for psychosocial concerns ranked lowest (0.3%). This surprised the authors who suggested that the counseling staff rather than the nurses may have been sought by campers to help with psychosocial concerns.

The study also examined the frequency with which campers sought assistance from the camp's health service. Some children were never seen (14%). Others ranged from one to five visits during their camp stay (47%) to very high use (9% of the sample was seen 16 to 40+ times). Campers with low use tended to come when injury or communicable disease especially the common cold prompted them to seek relief of distracting symptoms. This study found that both high and moderate users of the health center came most often because of communicable disease concerns.

Rauckhorst and Aroian looked at the relationship between a camper's age and the number and reason for their visit to the health service. In general, the older a camper, the less likely they would visit the health service at odd times. Younger campers tended to visit more for injury than older campers. Boys showed no significant relationship between age and frequency of visit, whereas younger girls were more likely to visit than older ones.

Gender had only slight impact on the relationship between age and reason for visit, but it did make a difference in frequency of visits. According to the authors, "...girls [were] more likely to visit the camp health center more frequently than boys in the middle of the camp season and at times other than the scheduled hours" (pg. 205). Gender also made a difference among those who sought health care for accidents/injuries. It's probably not a surprise to ACN readers that boys sought more help for this reason than girls. The opposite was true for general/constitutional symptoms (e.g., dizziness, fatigue, "don't feel well" comments); more girls sought care for these complaints than did boys.

IMPLICATIONS FOR THE PRACTICING CAMP NURSE

Supported by a number of tables and charts, the Rauckhorst-Aroian study is a rich source of information and full of suggestions for improving one's camp practice. If your camp health center is typical of the pattern which showed in this study, only a small portion of your campers (about 15%) account for the largest proportion of visits to your health center (>50%). This means that a majority of campers never "see the nurse" and gives reason for placing camp health promotion strategies such as drinking enough water, effectively washing hands, using sun screen in a context other than the health center per se. What cabin and activity counselors, for example, emphasize in these areas becomes critical. An effective staff orientation about camp-based health behaviors begins the process; in-season reminders (coaching sessions), particularly those which happen during weeks two and three, reinforce that message.

Another point in the study focused on age of camper. Rauckhorst-Aroian discovered that younger campers had a slight tendency for more total visits to the health center, more visits during their first two weeks at camp, and more odd time visits than older campers. This suggests a need for counselors who work with younger campers to focus on the campers' affiliation needs, making sure that each young camper feels emotionally comfortable in the cabin community. It also suggests that the camp nurse assess affiliation when working with camper concerns in the health service. Emotional health is just as important to wellness as physical health. Indeed, the ability of children to somatize emotion makes this assessment all the more important.

The system used to code "reasons for visits" in the Rauckhorst-Aroian study appears appropriate for use in other camp health centers. The authors' coding table (pg. 204) not only categorized reasons for visits but also listed a variety of symptoms in each category. By simply placing slash marks into respective boxes, a given camp could quickly develop a profile of their own camper and staff health center use patterns. This profile would be useful for orienting and training health center staff, for identifying priorities related to improving the camp's health profile, and for benchmarking improvements.

Study results showed that children sought health care most often because of accident/injury. Injury epidemiologists such as Robertson (1992), Wilde (1994), and Gookin (1998) stress the need to assess the context within which injuries occur for attributes which are amenable to risk-reduction intervention. Knowing that injury accounts for many health center visits, does it not make sense to probe the nature of injuries to determine which might be eliminated or at least reduced in severity? Is it not also ethically responsible to do so? I suggest that the camp health service which does not review incidents and adjust camp practices to minimize or eliminate personal injury does a great disservice to campers and staff.

Finally, this study provides testimony to the need for more research. Camp is an environment suitable to research. Given appropriate protection for human subjects, a camp setting is probably one of the most controlled environments within which to set a study. The range of health concerns, the interaction of human development in concert with health, and the ability to observe over time makes camp a particularly attractive setting. Of note, however, is the need to more fully understand the scope of camp health practice. That is possible with more studies such as the one by Rauckhorst and Aroian. Camp nursing is an emerging practice. Simply replicating this study would increase validity of study results and have benefit for both camp nurses and the people with whom they work.